It’s strange, our modern habit of responding to calamities by asking for advice from lawyers. Lady Justice Thirlwall yesterday published her report into how Lucy Letby was able to murder so many babies at the Countess of Chester Hospital. Thirlwall found “dysfunctional management”, patient safety “relegated below a flawed HR investigation of Letby’s grievance”, and a “complete failure to protect the babies”. Allocating fault retrospectively is her area of expertise. Whether it means she has now made the right recommendations is a different matter.

As a junior casualty doctor, I remember standing in the resuscitation room and expressing stupefaction at the fact my patient had unexpectedly gone into cardiorespiratory arrest. The nurse who was even then efficiently resuscitating them, Ben Geen, was later jailed for having injected them and others with the drugs that caused two deaths, and possibly many more. If I had been quicker to suspect him, he might have been stopped sooner. But I am not sure that a career spent being quicker to suspect my colleagues would have made me a better doctor or my patients safer.

So long as people have the power to act, they will have the power to kill, and that is especially true when it involves dangerous drugs and vulnerable patients. Minimising these horrors is important. But spotting murderers is not the chief job of healthcare. As the old motto goes, hard cases make bad law, and the jurist Oliver Wendell Holmes Jr thought great cases no better, because their fame arose from “some accident of immediate overwhelming interest which appeals to the feelings and distorts the judgement”. The mass murder of babies in a hospital certainly qualifies.

Some of what Thirlwall suggests is sensible. She is right that NHS managers are often awful, although she doesn’t ask why. She calls for them to be regulated, so that bad ones are not simply re-employed elsewhere. Failing upwards is traditional in NHS management, and putting a stop to it would be a human good, but it is less clear that you can regulate managers into being more honest, or thoughtful, or decent. The most viable option is stripping out a few of the very worst, which may not be as important as helping the majority of them become slightly better.

“The move towards a ‘no blame’ culture in the NHS, starting in 2000,” Thirlwall writes, “was a mistake. The focus on system faults rather than the failings of individuals … meant difficult conversations about conduct were avoided.” Yet the problem at the Countess of Chester was not a culture of “no blame”, but instead one where a management that the report calls “reprehensible” blamed the consultants raising concerns.

Former health secretary Jeremy Hunt championed the idea that British healthcare should adopt an aviation-style “no-blame” safety culture, and for good reason. Errors can only be prevented if they’re admitted, and they won’t be admitted if it isn’t safe to do so. Academic papers estimate suboptimal NHS care is responsible for around 10,000 deaths a year. Redesigning our approach to risk so that the next serial killer is caught more quickly would be catastrophic if it comes at the cost of sabotaging attempts to prevent those 10,000 deaths.

The NHS is wildly expensive and woefully bad. Designing its culture around recognising the next Letby or Geen is likely to make it worse.